BNH N DINH

DNG
H V TN: TRN TH THU HIN
T 6 Lp Y4B

I.

Hnh chnh:

1. H v tn: TRN THIN AN

2. Gii: N 3. Tui: 4,5 thng
3. Dn tc: Kinh
4. a ch: X Tn Tin, huyn Vn Giang, tnh Hng Yn.
5. H v tn b: Trn c Hiu 27 tui
Trnh VH:12/12
Ngh nghip: Cng nhn
6. H v tn m: L Th Nhung 25 tui
Trnh VH:12/12
Ngh nghip: k ton
7. Khi cn bo tin cho m : L Th Nhung (cng a ch)
ST:*********
8. Ngy vo vin: 08/06/2015
9. Ngy lm bnh n: 20h 09/06/2015

II. Chuyn mn

1. L do vo vin:chm tng cn
2. Bnh s:
Tr con th 1, c chn on tc rut bo thai lc

30w( cn nng c tnh 800g), non 31 tun, m

cp cu do m b THA-TSG, CN s sinh: 800g. Sau sinh
tr khc ngay, khng ngt, khng a phn su, sonde dd
dch vng xanh, nm lng p, n qua sonde. 7 ngy sau
sinh tr c phu thut ct on rut a 2 u rut ra
ngoi lm hu mn nhn to (cn 60cm rut).
Tr tip tc iu tr ti NHP 3 thng: 1 thng u nm
lng p, 2 thng sau iu tr vim phi nhim khun
huyt tiu chy. Tr khng c b sa non, 2 tun sau
sinh c ghp m v b sa nhng xut hin tiu chy
ngng b, tip tc c n sa cng thc qua sonde
(khng r lng). Ra vin sau 3 thng tr c 1300g,
hn khm nh k 2 tun/ln.

 tr v nh tip tc c cho n sa nutramigen (1

tha bt gt pha 30ml nc m/ln; ngy n 12 ln,

2h/ln). Ngoi ra tr c ung thm 40 ml ORS
hng ngy, ung t mt c ngy. Thng t4 tr tng
400g, hin ti tr 4,5 thng c 2kg.
Ngoi ra tr i ngoi phn lng, mu vng, khng
nhy, khng mu qua hu mn nhn to, ngy m
thay 5-6 ln, mi ln khong 40ml. tiu tin vng
trong, khng r gim s lng.
tr khng nn, khng st, thnh thong ho hng hng
khng m.
t ny tr theo hn khm, c nhp vin

 Hin ti:
Tr tnh, b c
ho hng hng khng m
khng st
i tin phn lng vng khng nhy

khng mu khng bt ngy 5-6 ln qua

HMNT
tiu tin vng trong

3. Tin s:
* Bn thn
3.1. Sn khoa:
Con th 1 (PARA 1111), thai lu 1 ln cch 9m
m cp cu do m THA-TSG 31 tun
Cn nng s sinh: 800 g
sau khc to,
khng ngt
Trong qu trnh mang thai, b m khng b bnh,
khng dng thuc, tng 17kg trong qu trnh
mang thai.
Qu trnh qun l thai nghn, tun 30 theo di tc
rut bo thai, cn d kin l 800g

 3.2. Bnh tt:

tc rut bo thai 30w
ct on rut a 2 u rut ra lm
HMNT 7 ngy sau sinh.
lng p 1 thng, iu tr VP-NKH-TC
ti NHP 2 thng.

 3.3 Nui dng:

khng c b sa non, khng c b

sa m (2w tr b m, sau b tiu chy,

nn b)
3 thng u iu tr ti vin n sa
cng thc qua sonde khng r lng
t thng t4 n sa nutramigen 12
ln/ngy(2h/ln. n c ngy m) mi
ln 30ml pha cng 1 tha bt gt.
40ml ORS hng ngy

 3.4. Pht trin:

*th cht:
Lc sinh: CN: 800g
3 thng u tng 500g
CC 43cm
thng t4 tng 400g
hin ti 4,5 thng 2000g (di -4SD) CC 45cm
*Pht trin tm thn: tr mi bit hng chuyn

(chm)
*Pht trin vn ng: cha bit ly cha cng c
(chm)
3.5. Tim chng: cha tim chng
* Gia nh:cha pht hin bnh l g lin quan

 4. Khm bnh:
4.1 Ton thn:
Bn tnh.
th trng suy kit: CN :2kg CC: 45cm
VN: 29cm VCT:7cm
V: 34cm
lp m di da (bng): 1,5 cm
c du hiu mc qun thng, np vo da mt chm
khng ph khng XHDD
da nim mc hng, lng bn tay khng nht
tc tha, hay ra m hi trm ban m, hay git mnh.
thp trc phng b mm 2,5*2,5 cm u bp
DHST: M130l/ph N: 36,5 NT: 45l/ph

 4.2 B phn:
4.2.1. Tiu ha:
Bng cn i, di ng theo nhp th,
khng chng, khng THBH, so m
ng trng gi trn v di rn
HMNT h chu (P) hi ty ti mp,
khng chy m
bng mm khng chng
gan lch khng s thy

4.2.2. Tun hon:

Lng ngc cn i, khng tun hon
bng h, khng so m c.
Mm tim KLS IV 1cm ngoi ng
gia n (T), khng din p bt
thng.
Tim u, 130 ck/ph, T1 T2 r
khng ting thi bnh l

 4.2.3. H hp:
ho hng hng t khng m
Lng ngc cn i, di ng theo nhp
th, khng RLLN, khng co ko c h
hp
th u, khng nhanh, 45l/ph
Phi thng kh c, RRPN r, khng
ran

 4.2.4. Thn kinh:

Tr tnh
Thp phng, 2,5*2,5cm b mm
HCMN (-)
HCTALNS (-)
Khng du hiu thn kinh khu tr.
4.2.5. Cc c quan b phn khc
khng pht hin g bt thng

 5. Tm tt bnh n:
Bnh nhi n, 4,5 thng tui, vo vin v

chm tng cn, bnh din bin 4.5 thng

nay. Qua thm khm, v hi bnh pht
hin cc hi chng, triu chng sau:
suy dinh dng nng: cn nng hin ti
2kg (di -4SD),cc 45cm, vct 7cm, lp m
di da 1,5 mm, khng ph, du hiu
qun thng, np vo da mt chm.
du hiu thiu vit D: tc tha, hay git
mnh, tot m hi trm,thp rng
2,5*2.5cm b mm.
du hiu thiu vitA, VitB1 khng r

 i tin phn lng mu vng qua HMNT

ngy 5-6 ln mi ln 40ml

khng c HCNT, HCTM
tin s tc rut bo thai 30w, non
31w, cnss 800g, m tc rut 7 ngy
tui, lng p 1 thng, iu tr VP-NKH-TC
2 thng ti NHP
chm tng cn chm pht trin tinh
thn vn ng

 6. Chn on s b:
suy dinh dng nng th marasmus/

HC rut ngn cn HMNT, non 31w

 7. Cn lm sng:
Yu cu:
cng thc mu
in gii
chc nng gan thn
yu t vi lng: Fe Mg

 Kt qu:
Cng thc mu ngy 8/6/2015
RBC/HGB/Hct: 3.35/101/30.3
MCV/MCH/MCHC: 90.4/30.1/333
WBC/NEUT%/LYM%: 19.71/18.9/65.9
PLT: 391

 Ha sinh: ngy 8/06/2015

Ure/Cre: 6.98/34.7
Protein TP: 61.72
Glucose: 5.14
Na/K/Cl/Ca/Ca ion:
125/6.9/100/2.36/1.120
GOT/GPT: 84.5/62.28
Mg:0.92
Fe: 11.71
P: 1.79

 G 8/6/15
Na/K/Cl:
120/3.28/92
CRPhs: 0.9

G 9/6/15
Na/K/Cl:
125/3.82/98

 8. Chn on xc nh:
suy dinh dng nng th marasmus
-RLG/ hc rut ngn cn HMNT,
non 31w